Posts Tagged ‘prostate gland’

Prostate Arterial Embolization To Treat Prostate Enlargement

February 18, 2017

Andrew Siegel MD  2/18/17

Note: Today’s entry was supposed to be on the topic of female stress incontinence, but this very interesting prostate topic presented itself to me, so the female incontinence entries will be continued next week.

Benign prostate enlargement (BPH) is a common condition of the middle-aged and older male in which the enlarging prostate gland obstructs urinary flow. It causes a number of annoying lower urinary tract symptoms, including a hesitant, weak and intermittent stream, prolonged emptying time, incomplete emptying, frequent urinating, urgency, nighttime urinating, and at times, urinary leakage. 

There are numerous treatment options available and one of the newest minimally invasive options is “super-selective prostate artery embolization”—a.k.a. “PAE”—a  procedure that is done by an interventional radiologist (a specialist x-ray doctor who does internal procedures without using conventional surgical techniques).  The blood supply to the prostate is purposely blocked (embolized) using micro-particles that are injected into one or more of the arteries to the prostate.  As a result of this embolization of the prostate artery, the part of the prostate served by the artery shrinks, opening up the obstructed urinary channel and improving the lower urinary tract symptoms.

Urinary difficulties attributable to BPH are commonly quantified using the International Prostatic Symptom Score (IPSS), a questionnaire consisting of seven symptom categories, with a range of increasingly severe symptom scores from 0 through 35. The score is based on the severity of each of the following lower urinary symptoms: hesitancy, decreased urinary stream, intermittency, sensation of incomplete emptying, nighttime urination, frequency, and urgency. The questionnaire responses are graded, with each of the seven symptom categories contributing a maximum of 5 points, for a total possible score of 35. Symptoms can be ranked as mild (0–7), moderate (8–19), and severe (20–35).  This IPSS is a useful metric both before and after a procedure like PAE, in order to document clinical symptomatic improvement.

Before pursuing PAE, a CT angiogram of the prostate is performed to determine prostate arterial anatomy, to help plan the PAE and to exclude patients with severe arterial disease or anatomic variations that will not allow PAE to be a consideration. Prior to pursuing a PAE procedure, it is vital to check PSA, perform a digital rectal examination and rule out prostate cancer.

 Technique of PAE

The PAE procedure takes place in the radiology department of the hospital under the supervision of the interventional radiologist. The femoral artery (thigh artery) is cannulated and by using an injection of contrast, the arterial supply to the prostate gland is identified. The prostate artery most commonly branches off the internal pudendal artery. Embolization of the anterolateral prostate artery, the main blood supply to the benign prostate growth, is attempted on both sides. The most challenging aspect is to identify and catheterize the tiny prostate arteries that are often only 1-2 mm in diameter.  Micro-particles (polyvinyl alcohol, trisacryl gelatin microspheres or other synthetic biocompatible materials) are injected into the prostate arteries to purposely compromise blood flow and cause partial necrosis (death of prostate cells) and shrinkage. After the embolization on one side, an angiogram (x-ray of pelvic arterial anatomy) is done before the sequence is repeated on the other side.


Because of variation in prostate arterial anatomy and the types of micro-particles used, the extent of necrosis and shrinkage of the prostate is quite variable. Furthermore, prostate volume reduction does not precisely correlate with symptom improvement.  Although ideally performed on both sides, when done only on one side (left or right prostate artery) it still results in improvement of symptoms without as significant a reduction in prostate volume.

Although clinical improvement in urinary symptoms is less predictable after PAE as compared to standard treatments including surgical removal or laser treatment of the obstructing part of the prostate, the PAE has numerous points in its favor. Advantages of this new procedure are avoidance of general anesthesia and surgery an preservation of ejaculation, as opposed to surgical treatments of BPH, which commonly cause retrograde ejaculation (ejaculating backwards into the bladder with semen following the path of least resistance).  The PAE procedure is ideal for the older male with symptomatic BPH and significant prostate enlargement who for one of a variety of reasons is not a good candidate for conventional surgery.

Side effects of the PAE include urethral burning, fever, nausea and vomiting and perineal pain from prostate ischemia (damage to the blood supply), short-term inability to urinate as well as the radiation exposure necessary to perform the procedure.

Bottom Line:  Growing evidence supports the use of prostate arterial embolization to treat benign prostate enlargement.  Selectively occluding the prostate arterial supply results in damage to the prostate blood supply and ischemic necrosis (prostate tissue death) with reduction in the volume of the prostate gland with improvement in symptoms.  Safe and effective, it is a promising minimally invasive option that is an attractive alternative to surgery for symptomatic patients with large prostates and concomitant medical problems who have failed to respond well to pharmacological treatments.

 Dr. John DeMeritt is an interventional radiologist at Hackensack University Medical Center in Hackensack, New Jersey, who has particular expertise and experience in PAE.  He reported the first case study of PAE in the USA, has conducted numerous studies on the topic as well as written several medical journal articles and has been interviewed on the subject by Dr. Max Gomez on CBS news:

Thank you to Dr. DeMeritt for provided me with information on the subject matter, both verbally and in the form of several excellent articles, including his original case report.  He also provided me with the PAE image.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health



Men Are From Mars, Women From Venus, But There’s Not Much Difference Between A Vagina And A Penis

December 10, 2016

Andrew Siegel MD 12/10/2016

What is it that most distinguishes a male from a female? The obvious answer is the genitals, with the penis/scrotum having a vastly different appearance from a vagina/vulva.  Despite the male and female genitals being the feature that most characterizes the difference between a male and female, there are striking similarities. The genitals of both sexes are biologically homologous– similar in structure and having a common embryological origin–with development into male versus female based simply on the hormonal environment at the time of development.  Today’s entry discusses the similarities (as opposed to the differences) between the genitals and the “homologues,” the specific anatomical structures that are of common embryological origin and are more alike than are commonly recognized. 

Whether one develops a penis or a vagina is determined at the moment the sperm penetrates the egg. The egg contains an X chromosome and the sperm either an X or Y chromosome. When the coupling results in an XX, the blueprint for female development is established; when the coupling results in an XY, the blueprint for male development is established. The bottom line is that the father determines the sex of the child.

Several weeks later, when the fertilized egg has turned into an embryo, the external genitals are identical. Female genitals are the “default” model, which will remain female, absent the presence of the male hormone testosterone (T). T is activated to dihydrotestosterone (DHT) that causes conversion of what would be a vulva and vagina into a penis and scrotum. Biochemical magic! The bottom line is that the developing embryo will remain female unless T/DHT are available to masculinize the external genitals.

In the young embryo there are three key genital structures: the “tubercle,” the “folds” and the “swellings.” In the absence of T/DHT, the genital tubercle (a midline swelling) develops into a clitoris. The urogenital folds (two vertically-oriented folds of tissue below the genital tubercle) become labia minora (inner lips). The labio-scrotal swellings (two vertically-oriented bulges outside the urogenital folds) fuse to become labia majora (outer lips). In the presence of T/DHT the genital tubercle morphs into a penis, the urogenital folds become the urethra and part of the penile shaft and the labio-scrotal swellings fuse to become a scrotum.

Genital Homologues

The penis is the homologue of the clitoris. Both structures are highly sensitive organs with a tremendous concentration of nerve fibers and contain erectile tissue (corpora) that enables them to expand in size and rigidity with stimulation. Both the penis and clitoris have a head (glans) and shaft and deep internal roots. Both are covered with a layer of skin that can be pulled back to expose the underlying anatomy. In the male this is referred to as the foreskin, which is the homologue of the female clitoral hood.


Comparison of penis (left) and clitoris (right)–note similar shape and internal structure, Attribution: Esseh, Wikipedia Commons

The male scrotal sac is the homologue of the female labia majora. The raphe (the seam that runs vertically up the perineum, scrotum and penis) is the homologue of the pudendal cleft (the slit between the labia) in the female.



Comparison of vulva (left) and scrotum (right); note similarity of outer labia to scrotum and female pudendal cleft to male raphe,  by Richiex (Own work) [CC BY-SA 3.0 ( or GFDL (, via Wikimedia Commons

The male prostate gland is the homologue of the female Skene’s glands. Both produce fluid that is released at the time of sexual climax. The male Cowper’s glands are the homologue of the female Bartholin’s glands, both of which secrete fluid at the time of sexual stimulation, pre-ejaculate fluid in the male and vaginal lubrication fluid in the female.



Male anatomy, note prostate gland and Cowper’s glands, by Male_anatomy.png: FAQ derivative work: Tsaitgaist (Male_anatomy.png) [GFDL ( or CC-BY-SA-3.0 (, via Wikimedia Commons


Note Skene’s gland and Bartholin’s glands openings below and to side of urethra and vagina respectively, by Nicholasolan (Skenes gland.jpg) [GFDL (, CC-BY-SA-3.0 ( or CC BY-SA 2.5-2.0-1.0 (, via Wikimedia Commons

Bottom Line: As different as female and male anatomy are, so they are similar.  The study of comparative genital anatomy and embryological origin is fascinating.  Next week’s entry addresses when this process of differentiation into male versus female goes awry, leading to “ambiguous” genitalia, and how the study of one such particular genetic defect led to the creation of a billion dollar blockbuster drug in common use for purposes of shrinking enlarged prostates and growing hair in men with male pattern baldness.   

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Andrew Siegel MD practices in Maywood, NJ.  He is board-certified in both urology and female pelvic medicine/reconstructive surgery and is Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and attending urologist at Hackensack University Medical Center. He is a Castle Connolly Top Doctor New York Metro area and Top Doctor New Jersey.

Dr. Siegel is the author ofTHE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health ( and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health ( 

Ejaculation: His and Hers

March 12, 2016

Andrew Siegel, MD   3/12/2016

One of the advantages of the specialty of urology is that it encompasses patients of both genders, unlike gynecology, which strictly involves females. Since I am board certified in Urology as well as in Female Pelvic Medicine, my practice allows me to have an equal balance of male and female patients. This gives me the opportunity to appreciate comparative male and female pelvic anatomy and function, which in reality are remarkably similar–a fact that may surprise you.

 A Few Brief Words on the Embryology of the Genitals.

Who Knew? Female and male external genitals are remarkably similar. In fact, in the first few weeks of existence as an embryo, the external genitals are identical.

The female external genitals are the “default” model, which will remain female in the absence of the male hormone testosterone. In this circumstance, the genital tubercle (a midline swelling) becomes the clitoris; the urogenital folds (two vertically-oriented folds of tissue below the genital tubercle) become the labia minora (inner lips); and the labio-scrotal swellings (two vertically-oriented bulges outside the urogenital folds) fuse to become the labia majora (outer lips).


(Comparison of genital anatomy,  1918 Gray’s Anatomy, Dr. Henry Gray, public domain)

In the presence of testosterone, the genital tubercle morphs into the penis; the urogenital folds fuse and become the urethra and part of the shaft of the penis; and the labio-scrotal swellings fuse to become the scrotal sac.  So, the clitoris and the penis are essentially the same structure, as are the outer labia and the scrotum.                                                                                              


Ejaculation is the expulsion of fluids at the time of sexual climax. The word “ejaculation” derives from ex, meaning out and jaculari, meaning to throw, shoot, hurl, cast. We are all familiar with male ejaculation, an event that is obvious and well understood and well studied. However, female ejaculation is a mysterious phenomenon and a curiosity to many and remains poorly understood and studied.

Male Ejaculation

Men often “dribble” before they “shoot.” The bulbo-urethral glands, a.k.a. Cowper’s glands, are paired, pea-sized structures whose ducts drain into the urethra (urinary channel). During sexual arousal, these glands produce a sticky, clear fluid that provides lubrication to the urethra. (These glands are the male versions of Bartholin’s glands in the female, discussed below).

Once a threshold of sexual stimulation is surpassed, men reach the “point of no return,” in which ejaculation becomes inevitable. Secretions from the prostate gland, seminal vesicles, epididymis, and vas deferens are deposited into the urethra within the prostate gland. Shortly thereafter, the bladder neck pinches closed while the prostate and seminal vesicles contract and the pelvic floor muscles (the bulbocavernosus and ischiocavernosus) spasm rhythmically, sending wave-like contractions rippling down the urethra to forcibly propel the semen out in a pulsatile and explosive eruption. Ejaculation is the physical act of expulsion of the semen, whereas orgasm is the intense emotional excitement and climax, the blissful emotions that accompany ejaculation.


(Male Internal Sexual Anatomy, permission CC BY-SA 3.0, created 18 April 2009)

What’s in the Ejaculate?

Less than 5% of the volume is sperm and the other 95+% is a cocktail of genital secretions that provides nourishment, support and chemical safekeeping for sperm. About 70% of the volume comes from the seminal vesicles, which secrete a thick, viscous fluid and 25% from the prostate gland, which produces a milky-white fluid. A negligible amount is from the bulbo-urethral glands, which release a clear viscous fluid that has a lubrication function. The average ejaculate volume is 2-5 milliliters (one teaspoon is the equivalent of 5 milliliters).

Who Knew?  While a huge ejaculatory load sounds desirable, in reality it is correlated with having fertility issues. The sperm can literally “drown” in the excess seminal fluid.

Female Ejaculation

This is a much less familiar subject than male ejaculation and a curiosity to many. Only a small percentage of women are capable of expelling fluid at the time of sexual climax.

The nature of this fluid is controversial, thought by some to be excessive vaginal lubrication and others to be glandular secretions. Although the volume of ejaculated fluid is typically small, there are certain women who ejaculate very large volumes of fluid at climax. Expulsion of fluid at climax may come from four possible sources: vaginal secretions; Bartholin’s glands; Skene’s glands; and the urinary bladder.


(Skene’s and Bartholin’s Glands, created 22 January 2007, original uploader Nicholasolan  en.wikipedia, Permission: CC-BY-SA-2.5, 2.0, 1.0; GFDL-WITH-DISCLAIMERS; CC-BY-S)

During female arousal and sexual stimulation, the vaginal walls lubricate with a “sweating-like” reaction as a result of the increased blood flow to the genitals and pelvic blood congestion, creating a slippery and glistening film. The amount of this lubrication is highly variable. Some women with female ejaculation can release some of this fluid at the time of climax by virtue of powerful contractions of the vaginal and pelvic floor muscles.

Bartholin’s glands are paired, pea-size glands that drain just below and to each side of the vaginal opening. They are the female versions of the male bulbo-urethral glands and during sexual arousal they secrete small drops of fluid, resulting in moistening of the opening of the vagina.

Skene’s glands (para-urethral glands) are paired glands that drain just above and to each side of the urethral opening. They are the female homologue of the male prostate gland and secrete fluid with arousal.

Scientific studies have shown that those women who are capable of ejaculating very large volumes are actually having urinary incontinence due to an involuntary contraction of the urinary bladder that accompanies orgasm. This is often referred to as “squirting.”

Bottom Line: In the animal kingdom (including human beings), sex is a clever “bait and switch” scheme. In the seeming pursuit of a feel-good activity, in reality—determined by nature’s evolutionary sleight of hand—participants are hoodwinked into reproducing. The ultimate goal of the reproductive process is the fusion of genetic material from two individuals to perpetuate the species.

The penis functions as a “pistol” to place DNA deeply into the female’s reproductive tract with ejaculation a necessity for the process. Similarly, the female genitals need to be sufficiently lubricated to optimize this process and the combination of vaginal lubrication from enhanced blood flow contributed to by Skene’s and Bartholin’s secretions will optimize nature’s ultimate goal.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym and PelvicRx, comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Arnold Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.  

Pelvic Rx can be obtained at, an online store that is home to quality urology products for men and women.  Use code UROLOGY10 at check out for 10% discount. 





“Welcome To The Club”

June 20, 2015

Andrew Siegel MD 6/20/15


(Thank you Pixabay for above image)

“Welcome to the club.” These four words have become my favorite response to a variety of the presenting complaints of my middle-age patients. As a fifty-something year-old male, I am a member of this club, the one in which things are not necessarily bad or problematic, but certainly different from the way they used to be.

I find that this sentence—gently stated in a heartening manner with a smile on my face—is calming and reassuring to my patients who are uncertain if they have a genuine medical issue that they might need to be concerned about. By being told that they are “members of the club,” they immediately understand that their complaint is not only common and shared by many of their peers, but also is to be expected and is not a major concern.

“Things fall apart, the center cannot hold.” –Chinua Achebe

Things change. We get older and we look and function differently…again, not necessarily badly, but differently. Unfortunately, humans do not come with a “user manual” that explains what to expect as we age, which could help us make the distinction between the normal expectations of aging as opposed to problems that demand medical attention. On my bucket list is to write such a “Manual of Man,” at least from a urology perspective, discussing the urinary, genital and sexual changes to be expected with the aging process. The challenge is to recognize the difference between “normal aging” and “pathological aging.”

On Becoming A Slack In The Sack

Sex Drive

After age 40, you are still interested in sex, but not nearly with the all-consuming passion you had decades before. Testosterone levels fall ever so gradually, resulting in this decrease in sexual appetite. That stated, libido seems to be the element of male sexuality that survives the longest, intact to some extent long after the penis functions only to allow you to stand to urinate. However, what was once a raging “fire” may now be mere “embers.”  It can be a source of great frustration to have functioning software but poorly functioning hardware!


You still may be able to get a respectable erection, but now it probably requires a bit more effort—often demanding touch for full arousal, whereas at one time it took only a smidgeon of erotic stimulation. Although the penis may be capable of getting hard enough for penetration, it has probably lost some of the rock-star majestic rigidity of yesteryear. Although the erection still can defy gravity, it might not have quite the angle it used to. On occasion the erection may soften before the sex act is completed. Nighttime and morning erections are fewer and farther between. Getting a second erection after climax is difficult, and you probably have more interest in going to sleep rather than pursuing a sexual encore.

Ejaculation and Orgasm

Ejaculation becomes noticeably different. The volume of semen is diminished and you question why you are “drying up.” Climax happens with less force and arc, sometimes just a mere dribble; your once “high-caliber rifle” is now a “blunt-nosed handgun.” Orgasms are unquestionably different with loss of some kick and intensity. At times, it may feel like nothing much happened—more “firecracker” than “fireworks.” Sperm quality also tends to go by the wayside with aging, but who really cares since procreation is for the next generation!

The penis often becomes less sensitive, not only making it more difficult to achieve and maintain an erection, but also at times giving rise to difficulty achieving climax, with delayed ejaculation. Perhaps this is an improvement over the premature ejaculation that may have been an issue when you were younger.

Changes In Genital Anatomy


Not a day goes by in my urology practice when I don’t hear the words: “Doc, my penis is shrinking.” The truth of the matter is that the penis can shrink from a variety of circumstances, but most of the time it is a mere illusion—a sleight of penis. Weight gain causes a generous pubic fat pad—the male equivalent of the female mons pubis—making the penis appear shorter. However, penile length is usually intact, with the penis merely hiding behind the fat pad, what I call the “turtle effect.”

There are genuine reasons for penile shrinkage such as treatments for prostate cancer including radical prostatectomy and testosterone deprivation as well as “disuse atrophy,” penile “wasting” resulting from not using the penis as nature intended. Additionally, with aging there is often a fatty plaque buildup within the penile arteries, loss of erection chamber smooth muscle and elastic tissue (replaced with scar tissue) and weakening of the pelvic floor muscles. This results in less elastic and expansive erection chambers that do not fill up and trap blood properly.  It also causes a loss in penile length, girth and the ability to maintain the high penile blood pressures that cause bone-hard rigidity. If scar tissue forms on the sheath of the erectile chambers, it can cause penile curvature and pain with erections, a.k.a. Peyronie’s disease.

On Becoming Slack In The Sac

While the penis may shrink, the scrotal sac expands, time and gravity being cruel conspirators. This smaller penis and larger and looser scrotum–appearing like the genitals of an old hound dog snoozing on the veranda–is not a particularly appealing sight! While the sac expands, the testicles often shrink in size. One of the complaints voiced not infrequently by middle-aged and older men is that their testicles hang down loosely, similar to pendulous breasts in older women. At times, men complain that when they sit on the toilet, their scrotum touches the toilet water. Ouch! The scrotum may hang so low that when you pass wind, your testicles may become airborne like a kite flying erratically in a sudden gust.

Urinary Woes

The only male organs that get bigger with age are our noses, ears, scrotums and prostate glands. Unfortunately, the prostate is wrapped precariously around the urethral channel and as the prostate enlarges it can constrict the flow of urine. You may observe a weaker stream that hesitates to start, takes more time to get going and longer to empty, starts and stops and the sensation that you have not emptied completely. You might notice that you urinate more often, get up one or more times at night to empty your bladder and when you have to go, it comes on with much greater urgency than it used to. Almost universal with aging is post-void dribbling, that annoying dribble that occurs after emptying your bladder.

Bottom Line: If you are a middle-aged male and are experiencing some of these symptoms, “Welcome to the club.” If these symptoms become annoying and interfere with your quality of life, it is time to check in with your friendly urologist!

Wishing you the best of health,

2014-04-23 20:16:29


A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Kindle, iBooks, Nook, Kobo) and paperback:

Co-founder of Private Gym:

available on Amazon and Private Gym website

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to properly strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic strength and tone. This FDA registered program is effective, safe and easy-to-use: The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximum opportunity for gains through its patented resistance equipment.


PSA Absurdity

January 31, 2015

Andrew Siegel MD   1/31/15


(Image designed  by Abby Cycotte for WAPC)

Prostate cancer is the most commonly diagnosed cancer in males (excluding skin cancers)—paralleling breast cancer in females in many ways—with an estimated 233,000 new cases diagnosed in 2014. Over the latest 5-year period for which data is available, the death rate for prostate cancer decreased based upon improved early detection and treatment. There are 3 million prostate cancer survivors in the USA. The vast majority of prostate cancers are diagnosed by Prostate Specific Antigen (PSA) screening, a simple blood test.

Prostate cancer screening with PSA has been the subject of intense controversy and debate, a controversy that I—as a practicing urologist—don’t quite get. A major backlash against screening occurred in 2012. It started with the United States Preventive Services Task Force (USPSTF) grade “D” recommendation against PSA screening and their call for total abandonment of the test. Of note, there was not a single urologist on the committee. The same organization had previously advised that women in their 40’s should not undergo routine mammography, setting off another blaze of controversy. As a busy clinical urologist for almost three decades, I was deeply disturbed by their recommendation.

In 2013 the American Urological Association (AUA) issued guidelines recommending against PSA testing before age 55, with testing every other year between ages 55-69 and then only after “informed decision making,” a discussion between physician and patient weighing benefits and harms.

AUA Guideline Statements:

  1. Do not screen men under age 40.
  2. Do not screen men age 40-54, unless high risk (family history or African American), in which case decision should be individualized.
  3. Screen men 55-69 after informed decision making.
  4. Screening interval of “two years or more” may be preferred to annual screening to reduce harms of screening.
  5. Do not screen men older than 70 or any man with life expectancy less than 10-15 years, although some men in excellent health may benefit from screening.

When these guidelines came out, I was in disbelief and shock. Why did the AUA—whose mission statement is “to promote the highest standards of urological clinical care through education, research and in the formulation of health care policy”—kowtow on this vital issue?

Further fueling the controversy and confusion is the lack of consensus among professional groups including the European Association of Urology, the National Comprehensive Cancer Network and the Prostate Cancer World Congress. Uncertainty in the lay press has prompted both patients and physicians to question PSA testing and recommendations for prostate biopsy.

Is there really any harm in screening? Screening provides information and there are no side effects aside from whatever complications may ensue from drawing a small amount of blood. There are potential side effects from prostate biopsy (although they are few and far between) and certainly there are potential side effects with treatment; however, it seems that both the USPSTF and the AUA have confused screening with treatment. The potential side effects of active treatment should not influence the diagnosis of prostate cancer by the proper means. “Treatment or non-treatment decisions can be made once the cancer is found, but not knowing about it in the first place surely burns bridges.”—Dr. Jay Smith

I ardently disagree with the assertions of the task force and the AUA. Urologists, radiation oncologists, and medical oncologists (those physicians who are in the “trenches” and take care of prostate cancer on a daily basis) understand how devastating prostate cancer can be and the importance of early detection.

So what has been the upshot of this controversy? What has happened is that instead of proceeding directly to prostate biopsy, many more men with an elevated or accelerated PSA are having repeat PSA testing (often fractionated to determine free PSA/total PSA), the PCA-3 urine test and a prostate MRI. If the regulatory agencies had cost savings on their agenda, they have failed miserably as more testing (that incurs a significant expense) is being done than ever before.

Busy urologists are seeing more and more indecision and equivocation among primary care physicians who are confronted with patients who want screening, but guidelines that suggest that it is not necessary. Despite the USPSTF recommendations and AUA guidelines, urologists are actually seeing more referrals for elevated PSA than ever before.

Hard Facts:

  1. PSA screening has resulted in downward stage migration—detecting prostate cancer in an early and curable stage, before it spreads and becomes incurable. If these guidelines are adhered to, we will most certainly give back the gains we have made and experience a reverse stage migration and a return to the pre-PSA era when up to 20% of men presented with advanced disease.
  2. PSA testing unequivocally reduces metastatic prostate cancer (cancer that has spread) and death from prostate cancer: USA death rates from prostate cancer have fallen 4% annually since 1992, five years after introduction of PSA testing.
  3. Rigid guidelines unfortunately do not allow for a nuanced and individualized approach to early prostate cancer detection. PSA has many shortcomings, but used intelligently and appropriately will continue to save lives.
  4. Baseline PSA testing for men in their 40’s is useful for predicting the future of prostate cancer.
  5. Not permitting men age 40-55 the opportunity for screening denies them the potential to diagnosis a disease that is potentially lethal; this population has a long life expectancy and therefore the greatest need for early diagnosis and curative treatment.
  6. Older men in good health with over a 10-year life expectancy should not be denied PSA testing simply on the basis of their age.
  7. 95% of male urologists and 80% of primary care physicians have annual PSA screening—clearly, those in the know feel that screening is beneficial.
  8. Death from prostate cancer is unpleasant, often involving painful metastases to the spine and pelvis and not uncommonly, kidney and bladder outlet obstruction; our charge as urologists is to try to not let this scenario come to fruition.

When interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. Marginalizing this important test does a great disservice to those who may benefit from early prostate cancer detection.

I have practiced urology in both the pre-PSA era and the post-PSA era. In my early years of training, it was not uncommon be called to the emergency room to treat men who could not urinate, who on digital rectal exam were found to have rock-hard prostate glands and imaging studies that showed diffuse spread of prostate cancer to their bones—metastatic prostate cancer with a grim prognosis. In the post-PSA era, that scenario—fortunately—occurs on an extremely infrequent basis thanks to PSA screening. The vast majority of men who present that way these days are those who have opted NOT to obtain a screening PSA as part of their annual physical exams.

Bottom Line: The downside of screening is over-detecting low-risk prostate cancer that may never prove to be problematic, but may result in unnecessary treatment with adverse consequences. The downside of not screening is under-detecting aggressive prostate cancer, with adverse consequences from necessary treatment not being given. We need to separate screening from treatment and screen smarter.”—Dr. Judd Moul

The major challenge for those of us who treat prostate cancer is to distinguish between clinically significant and clinically insignificant disease and to decide the best means of eradicating clinically significant disease to maintain quantity and quality of life. Not all prostate cancers require active treatment and not all prostate cancers are life threatening. The decision to proceed to active treatment is one that men should discuss in detail with their urologists to determine whether active treatment is necessary, or whether surveillance may be an option, appropriate in selected men with low-risk prostate cancer (low PSA; minimum number of biopsies showing cancer; low-grade cancer as determined by the pathologist). Those at greater risk can be managed appropriately (surgery or radiation) and many cured, avoiding the potential for progression of cancer and painful metastases and death.

“PSA is the best screening test we have for prostate cancer, and until there is a replacement for PSA, it would be unconscionable to stop it. Contrary to the USPSTF report, compelling evidence shows that PSA screening reduces prostate cancer deaths. This evidence needs to be shared with the public.”
–Dr. William Catalona

The Samadi Challenge For Prostate Cancer

Dr. David Samadi, Chief of Prostate Robotic Surgery at Lenox Hill Hospital, has created a challenge to women, since they are the proactive gender in terms of understanding the importance of health risks, screening and routine checkups and are often the driving force in men’s health.  Men are much more reluctant to engage with the health care system than women—particularly preventive health care—and Dr. Samadi sees women playing a pivotal role in encouraging men to focus on prostate health. On a larger scale, he sees women as ideal advocates and champions to help raise global awareness for prostate cancer. The Samadi Challenge involves women learning the risk factors for prostate cancer, improving the lifestyles of the men in their lives, encouraging men to have annual screening and in the case of being diagnosed with prostate cancer, urging men to seek appropriate treatment. Dr. Samadi launched a FaceBook page: “Women for Prostate Health,” a means to help women initiate a conversation about prostate health.

Wishing you the best of health,

2014-04-23 20:16:29

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Use It Or Lose It: The Wow of Human Plasticity and Adaptation

May 30, 2014

Blog # 156

Think for a momentabout orthodontics. Braces are applied to one’s imperfect teeth and ever so gradual increasing resistance is implemented over time and, presto, in a couple of years, the teeth are perfectly straight and beautiful.

Exposing our bodies to the right “environment” on a long-term basis can positively affect not only our external appearance, but also more importantly, our internal health. Conversely, exposing our bodies to the wrong environment on a long-term basis can negatively affect our external appearance and internal health.

Essentially, the cells and tissues of our bodies—including our muscles, bones, brains, and every other organ—are endowed with a remarkable capacity for “plasticity,” the quality of being able to be shaped and molded in an adaptive response to environmental changes. What it comes down to is that our human body is an adaptation machine.

Our composition is “fluid” as opposed to “static,” and our tissues are constantly being remodeled, restructured and refashioned in adaptive responses occurring in accordance to the forces, stresses, resistances and demands placed upon them. This plasticity is an amazing phenomenon and permits our tissues to maintain normal function when burdened with adverse “resistances.” Conversely, we can tap into this powerful resource by purposely challenging our tissues with the appropriate resistances to enable them to perform at extreme high levels of function.

An example of our bodies’ attempt to maintain normal function when burdened with adverse resistances is benign enlargement of the prostate gland.  Almost inevitably, all aging males experience this gradual growth of this curious gland wrapped around our urethral channels. As a result of this “crimp” on the urethra, the resistance to the flow of urine gradually increases. However, the bladder muscle adapts by hypertrophying (getting more muscular). The bladder ever so slowly changes from a thin and smooth muscle to a thick and rough muscle in order to generate the higher pressures necessary to enable getting the urine out through the impeded urethral passageway. The unsuspecting individual with this condition may experience no symptoms for quite some time because of this natural compensation. However, compensation cannot occur indefinitely as there are natural limits on this plasticity, so one day he may be unable to urinate because the bladder hypertrophy has become maxed out, yet the prostate growth and increased resistance continues relentlessly, resulting in a condition known as acute urinary retention.

Another example of our bodies’ attempt to maintain normal function when burdened with adverse resistances is hypertension, which totally parallels the situation with the prostate and the bladder. High blood pressure creates an environmental situation for the heart in which it needs to work harder to pump blood because of the increased resistance created within the walls of the arteries. Consequently, the muscle fibers of the heart hypertrophy, resulting in a larger and more muscular and powerful heart that can continue to pump blood effectively through the resistance of the high arterial pressure. The problem is that the “compensated” heart is subject to problems such as angina, arrhythmias and heart failure, and can get to the point—similar to the urinary bladder—where it decompensates and fails. Exercising the heart is desirable, but this is not the kind of exercise you want your heart to have

The powerful resource of plasticity and adaptability can positively and purposely be tapped into by challenging our tissues to adapt to the appropriate environmental changes (resistances) to enable our tissues to perform at extreme high levels of function. One type of resistance that is most beneficial is exercise.

Exercise is all about adaptation. The SAID principle (Specific Adaptation to Imposed Demands) posits that our body will adapt—in neuromuscular, mechanically, and metabolic terms—to the specific demands that are placed on it. This is the very reason why both endurance and resistance exercises get easier the more effort we put into doing them. Asthe body is subjected to gradual and progressive “overloads,” the heart, lungs and muscles adapt and a “new normal” level of fitness is achieved. It comes down to the fact that our muscles are plastic and capable of hypertrophy (growth) or atrophy (shrinkage) depending on the environment to which they are exposed.

I enjoy recreational cycling, but to date this season have not spent as much time in the saddle as I would have liked. I’ve been out for a number of 20-mile rides but last weekend went out with a friend for a hilly 50 miles. The last 10 miles were extremely difficult, as my body had not yet adapted to that kind of challenge; clearly I don’t have my cycling “legs” back yet. My heart and lungs were not the issue, but my glutes and quads were not up to the beating and challenge…but they will be in due time. Just as the marathon runner who gradually builds up to running the distance, so it is with every endurance sport

Adaptation to exercise is applicable to all aspects of fitness: cardiovascular or aerobic fitness in which the heart and lungs adapt to endurance efforts; musculo-skeletal fitness in which our muscles and underlying bony framework adapt to bearing loads and working against resistance, leaving our muscles sinewy, strong and toned; core strength, which is fitness of our torso muscles that allows us to maintain good posture, stability, balance and coordination as well as serving as a platform for efficient use of our arms and legs; and flexibility fitness in which our muscles are elastic, limber, supple and more resistant to injury.

Our bodies demand physical activity in order to function optimally. For example, our bones require weight bearing and biomechanical stresses in order to stay well mineralized and in peak functional condition, as bone mineralization is stimulated by the stresses brought on by a variety of movements. The same holds true for every organ in our body to maintain maximal functioning—they need to be employed and put into the service for which they were designed

“Use it or lose it.” As much as our bodies adapt positively to resistance, so they will adapt negatively to a lack of resistance. For example, after wearing a cast on one’s arm for 6 weeks, there is noticeable wasting of the arm muscles, known as “disuse atrophy.” Contrast this with the opposite scenario—exercising one’s arms by doing curls on a regular basis—which will result in an obvious hypertrophy of the arm muscles. When our bodies are sedentary—for example on the basis of a severe injury requiring bed rest—there is a rapid demineralization and thinning of our bones. Spinal cord injured patients who are paralyzed undergo just such a rapid demineralization. Astronauts who spend time in zero gravity (which takes all biomechanical forces away from the bones) experience a remarkably fast demineralization and risk not only thin bones—as does anybody with rapid demineralization— but also of developing kidney stones from the calcium mobilized from the bones. The process of adaptation is not limited to our muscles and bones, but involves each and every internal organ, including the kidneys, liver, pancreas, brain, etc. That is why it is so important to expose our bodies to positive “resistances” and not to “negative” resistances.

Our central nervous system is constantly being remodeled in response to environmental exposure. The brain’s neurons undergo anatomical changes and reorganization of their networks with new neural connections in response to new situations or environmental changes (learning). Through the processes of “neuroplasticity” and adaptation, learned behaviors actually modify the electrical hardwiring of the brain, which is dynamic and constantly subject to revision. Synaptic “sculpting” facilitates learning and synaptic “pruning” occurs when patterns are not repeated. Thus is explained on a biological basis how learning occurs.

Bottom line: Humans are bestowed with an amazing and magical capacity for plasticity and adaptation, which can be transformative when used to our advantage and benefit. Expose our bodies to positive cognitive and physical nourishment and they will be carved into beautiful, highly functioning machines. Expose our bodies to negative forces or absence of positive forces and they will falter into ugly, poorly functioning, maladaptive machines.


Andrew Siegel, MD

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook) and coming soon in paperback.


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Prostate: Bigger Is Not Better

November 24, 2013

Blog #129

The following quote from Gabriel Garcia Marquez’s Love in the Time of Cholera colorfully sums up the aging prostate:

“He was the first man that Fermina Daza heard urinate. She heard him on their wedding night, while she lay prostrate with seasickness
in the stateroom on the ship that was carrying them to France, and
 the sound of his stallion’s stream seemed so potent, so replete with authority, that it increased her terror of the devastation to come. That memory often returned to her as the years weakened the stream, for she never could resign herself to his wetting the rim of the toilet bowl each time he used it. Dr. Urbino tried to convince her, with arguments readily understandable to anyone who wished to understand them, that the mishap was not repeated every day through carelessness on his part, as she insisted, but because of organic reasons: as a young man his stream was so defined and so direct that when he was at school he won contests for marksmanship in filling bottles, but with the ravages of age it was not only decreasing, it was also becoming oblique and scattered, and had at last turned into a fantastic fountain, impossible to control despite his many efforts to direct it. He would say: “The toilet must have been invented by someone who knew nothing about men.” He contributed to domestic peace with a quotidian act that was more humiliating than humble: he wiped the rim of the bowl with toilet paper each time he used it. She knew, but never said anything as long as the ammoniac fumes were not too strong in the bathroom, and then she proclaimed, as if she had uncovered a crime: “This stinks like a rabbit hutch.” On the eve of old age this physical difficulty inspired Dr. Urbino with the ultimate solution: he urinated sitting down, as she did, which kept the bowl clean and him in a state of grace.”

The prostate gland is that mysterious, deep-in-the-pelvis male reproductive organ that can be the source of so much trouble.  It functions to produce prostate fluid, a milky liquid that serves as a nutrient and energy vehicle for sperm. Similar to the breast in many respects, the prostate consists of numerous glands that produce this fluid and ducts that convey the fluid into the urinary channel. At the time of sexual climax, the smooth muscle within the prostate squeezes the fluid out of the glands through the prostate ducts into the urethra (urinary channel that runs from the bladder to the tip of the penis), where it mixes with secretions from the other male reproductive organs to form semen.

The prostate gland completely envelops the urethra, enabling its many ducts to drain into the urethra. However, this necessary anatomical relationship between the prostate and the urethra can potentially be the source of many issues for the aging male. In young men the prostate gland is the size of a walnut; under the influence of three factors—aging, genetics, and adequate levels of the male hormone testosterone—the prostate enlarges, one of the few organs that actually gets bigger with time when there is so much atrophy (shrinkage) and loss of tissue mass going on elsewhere.

Who Knew?  As we age our muscles atrophy, our bones lose mass, our height shrinks and our hairlines and gums recede.  So why is it that our prostates—strategically wrapped around our urinary channels—swell up?

Prostate enlargement can be very variable; it can grow even to the size of a large Florida grapefruit!  As the prostate enlarges, it often—but not always—squeezes the sector of the urethra that runs through it, making urination difficult and resulting in a number of annoying symptoms and sleep disturbance.   It is similar to a hand squeezing a garden hose that affects the flow through the hose. The situation can be anything from a tolerable nuisance to one that has a huge impact on one’s daily activities and quality of life.

The condition of prostate enlargement is known as BPH—benign prostate hyperplasia—one of the most common plagues of aging men. It is important to identify other conditions that can mimic BPH, including urinary infections, prostate cancer, urethral stricture (scar tissue causing obstruction), and impaired bladder contractility (a weak bladder muscle that does not squeeze adequately to empty the bladder).

Although larger prostates tend to cause more “crimping” of urine flow than smaller prostates, the relationship is imprecise and a small prostate can, in fact, cause more symptoms than a large prostate, much as a small hand squeezing a garden hose tightly may affect flow more than a larger hand squeezing gently. The factors of concern are precisely where in the prostate the enlargement is and how tight the squeeze is on the urethra. In other words, prostate enlargement in a location immediately adjacent to the urethra will cause more symptoms
 than prostate enlargement in a more peripheral location. Also, the prostate gland and the urethra contain a generous supply of muscle and, depending upon the muscle tone of the prostate, variable symptoms may result. In fact, the tone of the prostate smooth muscle can change from moment to moment depending upon one’s adrenaline (the stress hormone) level.

Typical symptoms of BPH include an urgency to urinate requiring hurrying to the bathroom that gives rise to frequent urinating day and night and sometimes even urinary leakage before arriving to the bathroom.  As a result of these “irritative” symptoms, some men have to plan their routine based upon the availability of bathrooms, sit on an aisle seat on airplanes and avoid engaging in activities that provide no bathroom access.  One symptom in particular, sleep-time urination—aka nocturia—is particularly irksome because it is sleep-disruptive and the resultant fatigue can make for a very unpleasant existence.

The other symptoms that develop as a result of BPH are “obstructive” as the prostate becomes “welded shut like a lug nut.”  These symptoms include a weak stream that is slow to start, a stopping and starting quality stream, prolonged time to empty, and at times, a stream that is virtually a gravity drip with no force.  One of my patients described the urinary intermittency as “peeing in chapters.”  Many men have to urinate a second or third time to try to empty completely, a task that is often impossible. There may be a good deal of dribbling after urination is completed, known as post-void dribbling.  At times, a man cannot urinate at all and ends up in the emergency room for relief of the problem by the placement of a catheter, a tube that goes in the penis to drain the bladder and bypass the blockage. BPH can be responsible for bleeding, infections, stone formation in the bladder, and on occasion, kidney failure.

Not all men with BPH need to be treated; in fact, many can be observed if the symptoms are tolerable. There are very effective medications for BPH, and surgery is used when appropriate. There are three types of medications used to manage BPH: those that relax the muscle tone of the prostate; others that actually shrink the enlarged prostate gland; and Cialis that has been FDA approved to be used on a daily basis to treat both erectile dysfunction as well as BPH.  There are numerous surgical means of alleviating obstruction and currently the most popular procedure uses laser energy to vaporize a channel through the obstructed prostate gland.

In terms of the three factors that drive prostate growth: aging, genetics and testosterone: There is nothing much we can do about aging; in fact, it is quite desirable to live a long and healthy life!  We cannot do a thing about our inherited genes.  Having adequate levels of testosterone is actually quite desirable in terms of our general health.

So what can we do to maintain prostate health? The short answer is that a healthy lifestyle can lessen one’s risk of BPH.  Regular exercising and maintaining a physically active existence results in increased blood flow to the pelvis, which is prostate-healthy as it reduces inflammation. Sympathetic nervous system tone tends to increase prostate smooth muscle tone, worsening the symptoms of BPH; exercise mitigates sympathetic tone.  Maintaining a healthy weight and avoiding abdominal obesity, will minimize inflammatory chemicals that can worsen BPH.   Vegetables are highly anti-inflammatory and consumption of those that are high in lutein, including kale, spinach, broccoli, and peas as well as those that are high in beta-carotene including carrots, sweet potatoes, and spinach can lower the risk of BPH.  

Bottom Line: BPH is a common problem as one ages, oftentimes negatively impacting quality of life.  There are medications as well as surgery that can help with this issue; however, a healthy lifestyle that includes exercise, avoidance of obesity, and a diet rich in vegetables can actually help lower the risk for developing bothersome prostate symptoms.

Ten Steps To A Healthy Prostate 1. Decrease the amount of animal fat in your diet 2. Eat less meat and dairy 3. Eat more fish 4. Eat more tomatoes 5. Increase the amount of soy in your diet 6. Eat more fruits, veggies, beans, cereals and whole grains 7. Drink a cup of green tea daily 8. Maintain a healthy weight 9. Exercise regularly 10. Manage stress

Andrew Siegel, M.D.

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